Drugs Covered under Medicare Part D

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.CareImprovementPlus.com on the web.

Different out-of-pocket costs may apply for people who

have limited incomes,

live in long term care facilities, or

have access to Indian/Tribal/Urban (Indian Health Service) providers.

The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

In-Network

You pay a $0 annual deductible.

Initial Coverage

Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either:

A $0 copay; or

A $1.20 copay; or

A $2.55 copay

For all other drugs, either:

A $0 copay; or

A $3.60 copay; or

A $6.35 copay.

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

one-month (30-day) supply

three-month (90-day) supply

Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

one-month (31-day) supply of drugs

Mail Order

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

three-month (90-day) supply

Catastrophic Coverage

You pay a $0 copay.

Out-of-Network

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Care Improvement Plus Dual Advantage (Regional PPO SNP).

You can get out-of-network drugs the following way:

one-month (30-day) supply

Out-of-Network Initial Coverage

Depending on your income and institutional status, you will be reimbursed by Care Improvement Plus Dual Advantage (Regional PPO SNP) up to the plan's cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic), either:

A $0 copay; or

A $1.20 copay; or

A $2.55 copay

For all other drugs purchased out-of-network, either:

A $0 copay; or

A $3.60 copay; or

A $6.35 copay.

Out-of-NetworkCatastrophic Coverage

You will be reimbursed in full for drugs purchased out-of-network.

Optional Supplemental Benefits

Other Services

Inpatient Care

Doctor and Hospital Choice

In-Network

No referral required for network doctors, specialists, and hospitals.

In and Out-of-Network

You can go to doctors, specialists, and hospitals in or out of the network. It will cost more to get out of network benefits.

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Inpatient Hospital Care

In-Network

No limit to the number of days covered by the plan each hospital stay.

You will not be charged additional cost sharing for professional services.

$0 annual service category deductible*

$0 copay*

$0 copay for each additional non-Medicare-covered hospital day.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

Outpatient Care

Inpatient Mental Health Care

In-Network

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

$0 annual service category deductible*

$0 copay*

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

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Skilled Nursing Facility (SNF)

General

Authorization rules may apply.

In-Network

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

$0 annual service category deductible*

$0 copay for SNF services*

You will not be charged additional cost sharing for professional services

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Home Health Care

General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered home health visits*

Out-of-Network

$0 copay for Medicare-covered home health visits**

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Hospice

General

You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.

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Doctor Office Visits

In-Network

$0 copay for each Medicare-covered primary care doctor visit.*

$0 copay for each Medicare-covered specialist visit.*

Out-of-Network

20% of the cost for each Medicare-covered primary care doctor visit**

20% of the cost for each Medicare-covered specialist visit**

Outpatient Medical Services and Supplies

Chiropractic Services

In-Network

$0 copay for Medicare-covered chiropractic visits*

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).

Out-of-Network

20% of the cost for Medicare-covered chiropractic visits.**

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Podiatry Services

In-Network

$0 copay for Medicare-covered podiatry visits*

$0 copay for up to 6 supplemental routine podiatry visit(s) every year

20% of the cost for Medicare-covered Cardiac Rehabilitation Services**

20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services**

20% of the cost for Medicare-covered Pulmonary Rehabilitation Services**

Additional Benefits

Preventive Services

General

$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.

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